Acute lower limb ischemia in a patient with aortic thrombus and essential thrombocytosis

Abstract

Aortic thrombus is rare in patients with essential thrombocytosis (ET), so the optimal treatment remains undefined. A 45-year-old man with history of ET, under chronic treatment with aspirin, presented to the emergency department complaining of acute onset in both the legs and abdominal pain. Physical examination revealed that both dorsalis pedis pulses were not palpable with cold and pale feet. His abdomen was soft and nondistended. The platelet count was 436 x 10(9)/L. The thoraco-abdominal computerized tomographic scanning revealed normal aortic diameter with supraceliac and infrarenal nonoccluding thrombus and infarction areas in spleen and left kidney. At the emergency department he presented with recurrent symptoms, losing bilateral posterior tibial pulses. A decision was made to perform a thoracoretroperitoneal incision. A longitudinal sequential aortotomy was performed in the distal thoracic and infrarenal aorta, and the thrombus was easily removed. Following this, he underwent bilateral crural thrombectomy and local intra-arterial thrombolytic therapy. The postoperative course was uneventful. The left toes were amputated because of necrosis. He was discharged and put on antiaggregants, anticoagulants and hydroxyurea. Aortic thrombus in patients with ET is unusual, but potentially lethal. There is complete relief from symptoms in recurrent cases following surgery. An appropriate medical treatment after intervention must be supported.

Two effective cases of additional pedal artery angioplasty for severe lower limb ischemia following acute thrombotic artery occlusion with hypercoagulable state diseases

“…Catheter-directed thrombolysis, which is directly delivered within the thrombus in femoropopliteal lesions, is also a feasible treatment for ALI patients (Byrne et al 2014 ). These treatment strategies had been adapted in ALI patients associated with hypercoagulable state diseases in previous reports (Moulinet et al 2016 ; Chong et al 2016 ; Morata Barrado et al 2009 ). However, high thrombus burden associated with hypercoagulable state disease in ALI patients might deteriorate the vascular bed, increase peripheral artery resistance, and lead to poor pedal outflow.…”

“…A rare potential cause of ALI includes thrombotic artery occlusion associated with hypercoagulable state diseases, such as antiphospholipid syndrome (APS) and essential thrombocythemia (ET) (Suzuki et al 2016 ; Moulinet et al 2016 ; Chong et al 2016 ; Morata Barrado et al 2009 ). Successful revascularisation, including thrombectomy, bypass surgery, endovascular treatment, or hybrid treatment (surgical revascularization and endovascular treatment) for thrombotic artery occlusion in hypercoagulable state patients, has been reported (Moulinet et al 2016 ; Chong et al 2016 ; Morata Barrado et al 2009 ). However, revascularization in infrapopliteal lesions, including below-the-ankle (BTA) lesions, may be difficult because of poor run-off vessels, and elevated peripheral vascular resistance associated with microcirculation failure, due to a high thrombus burden.…”

Essential Thrombocytosis-Associated Thromboembolism in the Abdominal Aorta

“…In general, common causes of aortic thrombosis include cardiac sources of embolism, hypercoagulable states, and other complications from atherosclerotic disease. Although ET remains an uncommon cause of aortic pathology, some reports have discussed cases of ET-associated aortic mural thrombus [ 2 , 3 ]. To the best of our knowledge, this is the first such case report in Korea.…”

“…Thus, early diagnosis and prompt treatment is essential in cases of ET. Many options exist for managing ET, such as medical therapy with heparin anticoagulation, aspirin, and cytoreductive chemotherapy [ 2 , 4 ], and surgical treatment with aortic thrombectomy [ 3 , 5 ] and/or endovascular surgery [ 6 ].…”

“…In order to ensure the optimal treatment of ET, the location of the thrombus, potential for embolism, individual risk of the patient, and the pathology of the thrombus should all be considered jointly [ 3 , 5 ]. We decided to perform surgical treatment due to the rapid formation of the thrombus, the location of the original chronic thrombus, and the insufficiency of endovascular treatment.…”